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Chronic Sinusitis Article

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I found the following article on www.medscape.com I saved it to my hard drive, but I don’t still have the URL to point to. Since the article is not so long, I will post the whole article below. ———————— Approach to the Patient With Chronic Sinusitis First, it is imperative to take a careful history and review past medical records, with special attention to treatment options that have been used in the past, including antibiotic and corticosteroid use, past sinus surgeries, history of nasal or facial trauma, and past subspecialty consultation (eg, allergy and otolaryngology). Next, a thorough physical examination is important, and baseline fiberoptic rhinoscopy can be very helpful to delineate the patient’s anatomy. In addition, a baseline limited sinus CT scan will help document the extent of disease and clarify any other anatomic abnormalities, such as a deviated nasal septum. An allergy evaluation is also very important, since a failure to adequately address allergen triggers may cause a relapse of the disease after initial treatment. The patient should also be evaluated for associated asthma, since a significant portion of patients with chronic sinusitis may have associated asthma. Finally, a baseline absolute eosinophil count may be helpful, since persistence of eosinophilia despite medical treatment portends a less favorable response to more aggressive measures such as surgical intervention. If there is suspicion of immune deficiency (eg, history of recurring otitis media, bronchitis, pneumonia, or recurring infections with encapsulated organisms), then humoral immunity may be evaluated with IgG (total and subclasses), IgA, IgM, or specific immune responses. If there is suspicion of allergic fungal sinusitis (by CT scan or clinical presentation), then appropriate referral to a specialist for that evaluation should be done. Once the disease has been adequately staged, as noted above, the patient should receive "intensive medical therapy." This would consist of an antibiotic for 30 days, simultaneously started with prednisone for 8 to 10 days (see dosages below), nasal saline irrigations, intranasal steroid spray twice a day, and an (optional) oral decongestant (assuming no contraindications exist for these medications). The patient should then be re-evaluated and restaged in 1 month. Antibiotic choices should be guided by sinus cultures whenever possible, and the use of broader single antibiotic agents should be considered with or without the addition of anaerobic coverage with clindamycin or metronidazole. Antibiotic therapy should usually be given for 7 days after sinusitis symptoms have completely resolved. This may take 4 to 8 weeks. If symptoms recur soon after treatment is stopped, or fail to resolve with the above program, then an alternative antibiotic may be needed. Treatment failures occur more commonly in chronic sinusitis, compared with acute sinusitis. In general, patients who fail a prolonged course of combined prednisone and broad-spectrum antibiotics should be referred to an otolaryngologist for surgical consultation. There are only limited data to guide the treating physician on proper dosage of prednisone (used in conjunction with antibiotics) for the treatment of chronic sinusitis. A number of the symposium participants indicated that they had used different dosage schedules in this setting. One possible dosage regimen was suggested as follows: prednisone 20 mg orally twice a day for 4 days, followed by 20 mg orally every day for 4 days, then stop. It should be noted that the addition of oral corticosteroids to an antibiotic regimen for treatment of chronic sinusitis is a significantly different approach than those used in the past. Preliminary data suggest that it may be a very useful adjunct in this setting. However, patients and physicians alike need to be aware of the possible side effects of systemic corticosteroids. These must be weighed by the possible adverse consequences of chronic unresolved infection, risks of sinus surgery, etc. These judgments can only be made after close consultation between the treating physician and the patient, while taking all these factors into account. Topical intranasal steroids are also recommended, especially if the patient has a history of nasal polyposis. Intranasal steroids have been shown in several double-blind, placebo-controlled trials to improve nasal congestion and reduce the size or rate of growth of nasal polyps. Postoperatively, they have also been shown to help prevent the recurrence of nasal polyps after surgical polypectomy. Summary Management of chronic sinusitis presents a number of challenges to the treating physician. It is now becoming clear that, in addition to infection, inflammation may play a key role in the persistence of chronic sinusitis. If the inflammation that leads to mucosal thickening and sinus ostial occlusion is not addressed, it is much more difficult to successfully treat this condition. Further studies are needed to better clarify the role and proper dosage of both systemic and topical corticosteroids, when used alone or in combination with antibiotic therapy, in the management of chronic sinusitis. It is critical to identify allergen triggers to minimize the chance of future infections through effective allergen avoidance, etc. If patients fail to improve while on an intensive medical program, then referral to an otolaryngologist for surgical consultation may be indicated. References   1.. Hamilos DL. Resistant sinusitis: what to look for when usual measures fail. Program and abstracts of the American Academy of Allergy, Asthma and Immunology 60th Anniversary Meeting; March 7-12, 2003; Denver, Colorado.   2.. Slavin RG. Resistant sinusitis: What to look for when usual measures fail. Program and abstracts of the American Academy of Allergy, Asthma and Immunology 60th Anniversary Meeting; March 7-12, 2003; Denver, Colorado.   3.. Berrettini S, Carabelli A, Sellari-Franceschini S, et al. Perennial allergic rhinitis and chronic sinusitis: correlation with rhinologic risk factors. Allergy. 1999;54:242-248. Abstract   4.. Emanuel IA, Shaw SB. Chronic rhinosinusitis: allergy and sinus computed tomography relationships. Otolaryngol Head Neck Surg. 2000;123:687-691. Abstract   5.. Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg. 2000;123:S1-S32.   6.. Kaliner MA, Osguthorpe JD, Fireman P, et al. Sinusitis: bench to bedside. Current findings, future directions. J Allergy Clin Immunol. 1997;99:S829-S848. Abstract Copyright

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